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APPLICATION FOR CERTIFIED BANKRUPTCY ASSISTANT
Please complete the application in its entirety and comply with all of its instructions. If you have any questions, please email Dorothy Clay at claydo4@yahoo.com.
I. GENERAL INFORMATION
An
*
indicates a required response.
First Name
*
Last Name
*
Mailing Address
*
City
*
State
*
Zip Code
*
Phone Number
*
Email Address
*
IF YOU ARE RECERTIFYING SKIP TO V (RECERTIFICATION)
II. LEGAL EMPLOYMENT
Current Employer
*
Start Date (mm/yyyy)
*
Street Address
*
City
*
State
*
Zip Code
*
Title (Position)
*
Phone Number
*
Previous Employer
Start Date (mm/yyyy)
End Date (mm/yyyy)
Street Address
City
State
Zip Code
Title (Position)
Phone Number
Previous Employer
Start Date (mm/yyyy)
End Date (mm/yyyy)
Street Address
City
State
Zip Code
Title (Position)
Phone Number
III. EDUCATION/CERTIFICATIONS
College or Law School Attended
From
1930
1931
1932
1933
1934
1935
1936
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1991
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1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
To
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
Degree
College or Law School Attended
From
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
To
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
Degree
List any certifications.
Subject/Certification Granted
State
Date of Certification (mm/yyyy)
Subject/Certification Granted
State
Date of Certification (mm/yyyy)
How long has applicant worked in the bankruptcy field?
Years
*
IV. REFERENCES
Name bankruptcy attorney(s) familiar with applicant's work. The CBA Committee reserves the right to contact the attorney/employer for verification of all information provided by the applicant.
Reference 1
First Name
Last Name
Company Name
Phone Number
Street Address
City
State
Zip Code
Reference 2
First Name
Last Name
Company Name
Phone Number
Street Address
City
State
Zip Code
V. RECERTIFICATION
IF CERTIFICATION HAS EXPIRED WITHIN 4 YEARS OF LAST CERTIFICATION, APPLICANT IS REQUIRED TO ATTEND THE CBA PROGRAM. NO EXAM WILL BE REQUIRED.
Are you recertifying?
*
Yes
No
VI. COVENANTS
Please open the attached pdf to review.
Written Disclosure, Use of Program Materials and Rules & Regulations
https://fs22.formsite.com/abja/images/Application_Covenants.pdf
Acceptance and Acknowledgement
*
I agree that I have read the Application Covenants document containing the Written Disclosure, Agreement Regarding use of CBA Program Materials, and Rules and Regulations
/s/ Applicant's Electronic Signature (by typing name)
Date (mm/dd/yyyy)
/s/ Supervisor's Electronic Signature (by typing name)
Date (mm/dd/yyyy)